Access to primary care is worst in Quebec, but one-third report difficulty nationwide

While the contents of such an accord remain to be determined, recent public opinion polling from the Angus Reid Institute shows that the most important question for many Canadians will be whether it will do anything to improve their access to a system that is currently shutting them out.

Indeed, when it comes to primary care, more than one-third (35%) say they either don’t have a family doctor or are unable to get in to see their GP when they need to.

This segment of the population is considerably more likely to use walk-in clinics or emergency rooms for their primary care needs, and are more likely to express negative views about the overall quality of health care in Canada, as well as whether it’s improving or not.

Increasing access to general practitioners would go a long way toward both improving perceptions of the system and easing the primary care burden on organizations that were never intended to carry it.

Access to primary care

Consistent with other studies, ARI’s recent survey found that 16 per cent of Canadians do not have a family doctor. Roughly one-third of this group (5% of the general population) does not want one, but the rest have been looking – in some cases for years – and haven’t found one. This “No Access” group is joined by an additional 25 per cent of Canadians who say they have “Difficult Access” to their GPs:

These two health care “outsider” segments share much common ground in their experiences and attitudes towards the system.

The same can be said of the six-in-ten (60%) Canadians who are health care “insiders”, including one-in-four (24%) who have a GP and enjoy “Easy Access” to them, and another one-in-three (36%) who have “Acceptable Access” to their GP.

(This leaves one smaller segment – five per cent of the total population – who can be described as “not interested” and are not looking for a GP of their own. This small segment is heavily composed of young men and most are not feeling the need to access health care services at this time of life. Due to their lack of interaction with the system – and also the small sub-sample size – they are not featured in this research analysis.)

Problems of access to primary care are most acute in Quebec, where roughly four-in-ten (41%) belong to either “insider” group, compared to two-thirds of those in the Rest of Canada (ROC).

Relatedly, a full majority (52%) of Quebeckers have either Difficult or No Access to primary care (33% and 19% respectively). Across the ROC, meanwhile, one-in-three rated as “outsiders” (22% Difficult Access and 7% No Access).

While the variation between Quebec and the ROC is the most notable regional difference in access to primary care, there are other demographic differences, which can be summarized as follows:

Importantly, primary care access does not appear to be massively driven by socio-economic factors. These ARI findings show consistency in the access profiles of lower versus higher income Canadians and across formal educational strata.

Generationally, older Canadians are more likely to enjoy Easy Access – indeed, almost half this segment is over 55 (and, relatedly, they also access more health care services). The No Access segment tends a bit more towards younger people, including younger families (a cohort also getting squeezed on other fronts – notably homeownership in the nation’s largestcities).

Gender-wise there is broad equality in terms of insider versus outsider status, but within the latter we see more women in the Difficult Access group while there are more men who have No Access to primary care.

This has repercussions for the system

Access to primary care has important implications for the health care system. The collateral wear and tear on other health care access points is the subject of much academic research. In 2014, Statistics Canada found that 81 per cent of the roughly 4.5 million Canadians without a regular doctor had a place that they usually go when sick or in need of health advice – in most cases, a walk-in clinic.

This recent ARI survey yielded similar results, with a total of 25 per cent of Canadians surveyed saying they had gone to a hospital ER this past year for something they could or would have seen a GP for, and 40 per cent saying they had used a walk-in clinic for the same purpose. Many made multiple visits to these alternate health care venues.

This is highly correlated with access to primary care, as seen in the following graph:

There has also been a great deal of research on differential patient outcomes based on the quality and accessibility of primary health care services.

This ARI survey simply asked surveyed Canadians if a medical professional had made any errors in their care in the past year. One-in-ten of all respondents reported this had happened to them — ranging from seven per cent of the Easy Access segment up to 16 per cent of those with Difficult Access.

Access also impacts satisfaction with GP visits

Access to primary care is also strongly correlated with patient satisfaction with various elements of the Canadian health care system, beginning with the GP experience itself. Specifically,

Those who have Difficult Access to their GP are significantly less likely to say they were “extremely” or “very satisfied” with their last visit: 55 per cent of the Difficult Access segment were this satisfied with their last GP visit compared to three-quarters of their counterparts with Easy (79%) or Acceptable Access (74%) to their GP.

The same overall pattern can be seen in other aspects of GP interaction. Across five specific dimensions assessed, those with Easy Access gave much higher overall satisfaction ratings than those with Acceptable or difficult Access – with an average satisfaction gap of 15 points, rising to more than 20 points in the case of “the amount of time the GP spent with me”.

And other patient interactions with the health care system

This also goes beyond the GP experience alone and casts some shadow on other points of contact with the health care system. For example:

In the case of medical specialists, three-quarters of those in the Easy (76%) and Acceptable (73%) segments who had seen a specialist this past year gave an excellent or very satisfied assessment; this specialist visit satisfaction level declines to 58 per cent of the Difficult Access segment and only 49 per cent of those with No Access.

For hospital emergency rooms/ER’s, the survey records lower satisfaction levels overall with a more modest 38 per cent of all past year ER visitors saying they were extremely or very satisfied with their most recent visit, while one-in-three (30%) voiced some degree of dissatisfaction. Again, one’s access to primary care plays a role in Canadians’ ER visit assessments with high satisfaction voiced by 62 per cent of Easy Access ER visitors, down to 40 per cent of those with Acceptable Access, down again to only 27 per cent of those with Difficult Access and 25 per cent of those with No Access to traditional primary care.

And for walk-in clinics, we also see more modest satisfaction levels with 44 per cent of all past year visitors voicing high satisfaction with their last visit. Again, this patient satisfaction level declines from 51 per cent of walk-in visitors who have Easy Access to their own GP, down all the way to 30 per cent among those with No Access to a GP of their own.

And assessments of the health care system overall

Access to primary care not only drives individual Canadians’ perceptions of their own experiences with the health care system, it also affects how they view the system’s overall quality.

Those who have good access to primary care – the Easy Access and Acceptable Access segments – are much more likely to rate the overall system as “excellent” or “very good”, while those in the Difficult Access and No Access groups are roughly three times as likely as the other two groups to rate Canada’s health care system as “poor” or “very poor,” as evidenced in the following graph:

This survey also asked Canadians whether they think the country’s health care system has improved, stayed the same, or deteriorated over the past 10 to 15 years. Across the whole sample, only 16 per cent believe the health care system has improved during this time compared to 42 per cent who believe it has deteriorated (the remaining 42% said it has stayed the same).

To facilitate easy comparisons across groups, a “momentum score” can be calculated by subtracting the percentage who say the system has deteriorated from the percentage who say it has improved. The rather downcast assessment among the total sample yields a score of -26 (16% improved minus 42% worse).

While each access segment gives the health care system a negative score, those with Easy Access have a significantly less negative perception of the system than the other groups:

Those in the Acceptable Access segment are roughly on par with the overall population. The two cohorts with limited access to the system – the Difficult Access and No Access groups – give the system considerably more negative scores.

Personal experiences with access to primary care also shape Canadians’ views on the government’s administration of the health care system. While health care is a provincial responsibility, the federal government provides the bulk of the funding for each province’s system. For this reason, ARI asked respondents how satisfied they were with each level of government’s handling of health care.

As it turns out, opinion on this question doesn’t vary much by level of government. Canadians of all levels of access to the system rated their satisfaction with the provincial and federal governments roughly equally. That said, those who have Easy Access or Acceptable Access to the system are more likely to be “very satisfied” or “moderately satisfied,” while those who struggle with access are less so:

Note that less than half of the total population is satisfied with either their provincial or federal government’s handling of health care. Clearly, there is a great deal of room for improvement – particularly among those “outsider” groups – that the new government will be looking to capitalize on in developing its new health care accord. Whether it’s able to convert those with Difficult or No Access into health care “insiders” will go a long way toward determining how successful such an accord will be.